Nontuberculous Mycobacteria and the Environment (Insights from Hawai’I)

Nontuberculous mycobacteria and the environment (insights from Hawai’i)

Jennifer R. Honda, PhD 23rd Annual Conference of the Union-North America Region Post-Graduate Course 2-20-19 What’s the myco difference? Mycobacterium tuberculosis (M.tb) Nontuberculous mycobacteria (NTM)

Lung, intracellular Ubiquitous environmental distribution

Typical place of residence:

Mycobacterium abscessus species M. gordonae Mycobacterium avium complex (MAC) M. terrae M. avium M. gilvum Pathogenicity M. intracellulare M. smegmatis ruler: M. chimaera 10 9 8 7 6 5 4 3 2 1

Causes TRUE lung disease Opportunistic pathogens Rarely causes lung disease

Overall available knowledge: NTM lung disease

• General population are constantly exposed, but infection is rare. • Most common of the ”rare lung diseases.”

• General population: 4-7/100,000 persons • Elderly (>65yr) 15-47/100,000 persons

• Outbreaks of NTM have occurred.

• Treatment is inadequate, lengthy, and expensive.

• Person-to-person transmission is not known to occur, but may occur in patients with cystic fibrosis in close proximity to infected persons. Why do we care about NTM lung disease?

Changing prevalence of NTM and TB in the U.S. Inadequate knowledge

NTM

Zheng, et al. Q J Med, 2013

• In the U.S., nearly 180,000 individuals are infected with NTM. Major mycobacterial lipids • Prevalence is increasing at >8.2% annually. Tran, T. et al, Tubercu J, 2019; under review Contributing host and environmental factors

Virulence of NTM

Most

HOST-RISK FACTORS Least ANATOMIC ENVIRONMENTAL Prior bronchiectasis EXPOSURE Emphysema Aerosolized water (hot tubs, Pneumoconiosis showerheads) Chronic aspiration Aerosolized soil exposure Calcified chest adenopathy Residence in Southeast U.S. and IMMUNOLOGIC-GENETIC Hawai’i Cystic fibrosis, CFTR anomalies Alpha-1-antitrypsin anomalies Pulmonary alveolar proteinosis Partial deficiency in IFNg(?) TNFa antagonists* Inhaled corticosteroids Multigenic disorder Completely normal hosts Ciliary defect (MST1R) (size of inoculum matters?) Host-susceptible phenotype of unknown cause Slender individuals with Marfanoid body habitus (scoliosis, pectus excavatum, mitral valve prolapse)

Honda et al Clinical Handbook on NTM, 2017. M. MARSEILLENSE M. LLATZERENSE M. MONACENSE M. MALMOENSE M. MUCOGENICUM What are the most common NTM species M. MARINUM M. NEBRASKENSE M. YONGONENSE M. NEOAURUM identified in patient respiratory specimens M. ALVEI M. NONCHROMOGENICUM M. ARUPENSE M. NOVOCASTRENSE at National Jewish Health? M. ASIATICUM M. OBUENSE M. BOUCHEDURHONENSE M. PALUSTRE M. CELATUM M. PARAENSE Mycobacterial Clinical Labs M. CHLOROPHENOLICUM M. PARAFFINICUM U.S. NTM isolates (7/2013-7/2015) M. COLOMBIENSE M. PARASCROFULACEUM M. CONCEPTIONENSE M. PEREGRINUM M. CONSPICUUM M. PHLEI Of 3,096 NJH isolates, these are the top 7: M. COOKII M. PHOCAICUM M. COSMETICUM M. PORCINUM (66%) M. ELEPHANTIS M. SASKATCHEWANENSE M. EUROPAEUM M. SCROFULACEUM 15.83% M. ABSCESSUS M. FARCINOGENES M. SENEGALENSE M. FREDERIKSBERGENSE M. SENUENSE 12.63% M. AVIUM M. GASTRI M. SEPTICUM 9.01% M. FORTUITUM M. GENAVENSE M. SETENSE Total=100% M. GOODII M. SHERRISII 8.91% M. INTRACELLULARE M. GORDONAE M. SIMIAE 8.85% M. MASSILIENSE M. HAEMOPHILUM M. SMEGMATIS M. HASSIACUM M. STOMATEPIAE 5.46% M. CHELONAE M. HECKESHORNENSE M. SZULGAI M. HIBERNIAE M. TERRAE M. HODLERI M. THERMORESISTIBLE M. IMMUNNOGENUM 5.33% M. CHIMAERA M. TIMONENSE * M. INTERJECTUM M. TRIPLEX M. IRANICUM M. TRIVIALE M. KANSASII M. WOLINSKYI M. KUBICAE M. XENOPI M. KUMAMOTONENSE M. LENTIFLAVUM M. LITORALE How are infections acquired? Inhalation of NTM aerosolized from environmental sources

Drinking water Heater-cooler Heater-cooler distribution units Drinking water units distribution systems Animals Animals Faucets, ice systems Faucets, ice machines machines Acidic, brown Water tanks Acidic, brown Water tanks water swamps water swamps Hot tubs/spas Hot tubs/spas Showerheads Soil Soil Showerheads Forest soil and Boreal forest soil peats and peats

Studies have reported NTM in a variety of different geographic locations. But NTM diversity has never been comprehensively characterized in a single, large geographic area. e.g., Asia, Europe, Africa, U.S. Environmental NTM Biofilms • U.S. showerheads are enriched for NTM (Feazel, 2009).

• Identical NTM fingerprints from the NTM isolates from patient lungs and their matched shower water isolates (Falkinham, 2008; 2011).

• Showerhead biofilms are the most frequently sampled environmental sources to describe the presence of environmental NTM globally.

Mycobacterium Cut open shower hoses reveal diverse biofilms Shower hose biofilms

Proctor, et al Water Research, 2018 Soto-Giron, AEM 2016 Showerhead Microbiome and NTM Lung Disease

Showerhead Microbiome Project (Gerbert et al, mBio, 2018) Hawai’i is a U.S. Hot Spot for NTM Lung Disease

• A 1979 survey of public health laboratories showed Hawai’i had the highest M. avium complex isolation rate in the U.S. (Good, 1980).

• Hawai’i has the highest prevalence - 396 cases/100,000 population among persons > 65 years-old (1997-2007). (Adjemian, AJRCCM, Vol 185, 2012)

• High-risk environments for NTM in particular geographic areas of Hawai’i. (Adjemian, AJRCCM, Vol. 186, 2012)

• Hawai’i also demonstrates the highest, national age-adjusted mortality rates from NTM-LD. (Mirsaeidi, 2014)

CA: 191 AZ: 179 LA: MS: FL: 178 165 176 HI: 396 Current Lab Directions

Hawai’i

i.e., environmental water biofilms, soil, animal reservoirs, climate, etc….. Hawaiian Islands

NTM lung disease

i.e., host genetics/immunity, behaviors Honda, et al Frontiers in Microb, 2018 i.e., species pathogenicity Epidemiology of NTM lung disease in Hawai’i

• Retrospective study, EMR database query (2005-13)

• ~ 373,168 patient enrolled large healthcare system in Hawai’i – 1/3 of the state’s population

• Period prevalence highest: 1) Oahu (153/100,000 cases); 2) Maui (91/100,000 cases), 3) Big Island (84/100,000 cases). No cases identified on other islands.

• Highest among Japanese, Chinese, Korean, Vietnamese; lowest among Native Hawaiian/Other Pacific Islanders.

59.67% MAC

17.90% M. abscessus complex 22.43% M. fortuitum group

Adjemian, et al, EID, 2017 Total=486 clinical isolates NTM species in respiratory specimens from Hawai’i n = 140 Oahu isolates (2018)

2.0% M. porcinum

2.7% M. avium 3.4% M. intracellulare 4.7% M. fortuitum

6.7% M. abscessus

18.1% M. massiliense

51.7% M. chimaera

M. arosiense M. kubicae M. yongonense M. parascrofulaceum M. timonense M. senegalense M. bolletii M. simiae M. phocaicum First discoveries of NTM in Hawai’i households, 2012

75 households samples 172 household plumbing biofilms and soil

No M. avium identified.

M. intracellulare was very rare.

Honda, et al, PLOS Neg Trop Disease, 2016 Hawai’i 2018 environmental samples ~ 1,500 new samples

Analyses of the first 2012 219 new samples Households

37% 63% Household Non household Kauai – HH=83% (5/6) vs Non-HH=21% (6/28) Oahu– HH=90% (10/11) vs Non-HH=32% (18/57)

Maui – HH=75% (3/4) vs Non-HH=23% (5/22) Hawai’i Island – HH=73% (8/11) vs Non-HH=92% (12/13) NTM recovery by island, island, by 2018 recovery NTM Environmental species diversity

Novel NTM 50 youngest M. phocaicum 25 Hawai’i M. neoaurum d M. mucogenicum

r Island

e M. iranicum

v 20 40 s

o M. immunogenum

p g M. gordonae

p s M. gilvum

15 a

e Maui

a M. conceptionense

s 30

s I M. canariasense

10 M. arceuilense

Oahu M. wolinskyi

N M. timonense

b 5 20 f

N M. simiae

n M. porcinum

o Kauai i t M. intracellulare

% 0 r

o i M. fortuitum

s e a e e e e e e e p u a m r m m m m m m a a s y s s s m m r M 10 s n u e u u u u u u n i n k n n n u u a T t r i l o s o in a ic i lv ic n ic o m e s e e e v u N M. chimaera e l a u i e i n in il s n u a l l r c e rc im t g n g n rd s l a a l e h h c r . ra o e . o o u i io o . e v s o o o g o e r t c P b c p c h f M i n g M im w c a e M a o M. chelonae a . . . . . u o . t . r p n r N . M p M c . a n e . t M M . M m u M M . a c M in M M m M c n . M. avium im . M . o . M c M M M . M. abscessus M 0 Kauai Oahu Maui Hawai'i Are all showerheads hot spots for NTM?

Household showerhead biofilms Beach showerhead biofilms

53% (23/43) NTM positive 20% (10/50) NTM positive Total # showerheads tested (n=93) M. avium discovered in Hawai’i streams

• M. avium absent from the 2012 Hawai’i study Oahu stream biofilms

e 4

N 0 e a e • 2018 - 75% (6/8) samples collected from Oahu m a r r M iu n e la T v o a u N a l m ll l streams were NTM positive. . e i e e h h c v M c c a o . . r N M t M in . M Interim summary A study within the study M. gilvum M. gordonae M. timonense M. wolinskyi M. mucogenicum What is a Hawai’i specific factor that could impact M. simiae M. immunogenum M. fortuitum NTM lung disease? M. phocaicum M. arceuilense M. conceptionense M. neoaurum M. iranicum M. canariasense Kilauea Volcano, 1-17-18 100

M.avium

M. intracellulare s

e l 60

p M. porcinum

f M. abscessus

g 40

e M. chimaera

P 20 M. chelonae Kīlauea Volcano's lower E. Rift Novel NTM zone on 5-19-18, ~8:18 AM, HST. 0

m ld d a o l e h o tr e h s e Kilauea, Halema’uma’u, 5-9-18 S u s o u H o -h n Bottom images courtesy of USGS o N Kilauea’s potential association with NTM lung disease?

• Volcanic ash - tiny jagged pieces of rock and glass. • Abrasive ash particles can be inhaled into the lungs • Spread over broad areas by wind • Ashfall can enter water systems and soil. Photo credit: Baron Sekiya/ Hawaii 247.com

• Direct: NTM laden ash can be inhaled into the lungs resulting in infection.

• Indirect: Volcanic soils/water provide a niche that foster growth of NTM already in the environment. NTM and the Kilauea volcano

Before eruption - 1/17/18-1/19/18 Kilauea Summit Kilauea SW Rift Crooks 1

Pasture

Fly9 Mauna Iki

HRPLO 39 soil/ash/cinder samples collected 7 households sampled

Tamar Elias >>>vegetation < vegetation HVO, USGS Volcano soil composition and NTM

Al2O3 CaO

Fe2O3

K2O MgO MnO MoreP2O5 is Na2O associated with

Phosphorous pentoxide P2O5 higher odds sample will SiO 2 contain NTM. TiO2 Non-NTM and NTM recovered from Kilauea, Jan. 2018 Non-NTM NTM Total=52 Total=58 19.23% M. chelonae 31.03% Bacillus tropicus

9.62% M. triplex

3.85% 9.62% M. abscessus M. chimaera 8.62% Rhodococcus equi 5.77% novel 7.69% M. timonense NTM 8.62% Rhodococcus hoagii Streptomyces 7.69% M. genavense avermitilis Methlylobacterium 7.69% M. avium phyllostachyos Paenibacilus pabuli Rhodococcus agglutinans M. paraffinicum M. florentinum Paenibacilus susongensis Rhodococcus soil M. parascrofulaceum M. marseillense Reyranella massiliense Paenibacilus doosanensis M. parmense M. arcueilense Paenibacillus thiaminolyticus Burkholderia rinojensis M. saopaulense M. gordonae Afipia broomeae Streptomyces adustus M. stomatepiae M. palustre Bordetella bronchialis Streptomyces cerasinus M. salmoniphilum M. franklinii Bradyrhizobium sp. SK17 Streptomyces lactacystinicus M. septicum M. europaeum Clostridium intestinale Paenibacilus filicis Cutibacterium acnes Paenibacilus ihumii Gorillibacterium massiliense 24/35 unique soil sample location sites Kilauea steam vent M. abscessus Respirable ash Fine ash fraction fraction

Kilauea ash recovered on 5-28-19 SEM

Kilauea M. abscessus binds to Kilauea ash.

x 9,000 magnification x 2,500 magnification Is NTM detectable the ash samples? A) Respirable Ash B) Fine Ash

M. abscessus M. abscessus

M. avium M. avium What has Hawai’i taught us about environmental NTM? • High recovery of NTM from households compared to non-household sources. o Household showerhead biofilms contain significant more NTM than beach.

• Clinically relevant M. abscessus and M. chimaera are found on all islands tested.

• NTM recovery varies by island: Less NTM on Kauai and Maui; more NTM on Oahu and Hawai’i Island.

• Hawai’i Island shows high diversity of NTM and novel species.

• M. avium can be recovered from Hawai’i streams and the Kilauea Volcano.

• Kilauea and its ash maybe a new risk factor for NTM lung disease in Hawai’i. Acknowledgements Kaiser Permanente NOAA Center for Health Research National Jewish Health Virginia Tech National Centers for Honolulu, HI: Denver, CO Blacksburg, VA Environmental Stacey Honda, MD Joe Falkinham, III, PhD Information, Honolulu, HI Vanessa Simiola, PhD Edward D. Chan, MD Myra Williams John Marra, PhD Emmalyn Pilande Michael Strong, PhD Janet Myers, MD Yihe Dida, PhD Nabeeh A. Hasan, PhD ERT, Inc., at NOAA Tim Frankland L. Elaine Epperson, PhD Volcano Science Center National Centers for James Crooks, PhD USGS Environmental Information, Diagnostic Laboratory Cody M. Glickman Menlo Park, CA Asheville, NC Services: David E. Damby, PhD Michael Kruk Xiyuan Bai, PhD Aiea, HI Shanae Aerts Matt Bankowski, PhD Hawai’i Volcano Observatory NIH: Rebecca Davidson, PhD (to 2017) & USGS: Bethesda, MD Randy Anselment Terrie Koyamatsu Volcano, HI Jennifer Adjemian, PhD Honda Lab Paul Reynolds, PhD Tamar Elias (to 2018) Brigham Young University Ravleen Virdi Lisa Zhou, MD Morgan Nasholds Becky Prevots, PhD Department of Geological Sciences Stephanie Dawrs Zhihong Feng, MD Shauna Bladt Charles Daley, MD Provo, UT Grant Norton Gail Ferguson U of Colorado, Niels Helstrom Mike Pearson Boulder, CO: Steve Nelson, PhD Max Salfinger, MD Howard Hoshide Noah Fierer, PhD Schuyler Robinson Brandon Hellbusch Tina Neal Matt Gerbert Kevin Rey

Funding: National Science Foundation Ecology, Evolution and Infectious Disease (#1743587), Padosi Foundation, Shoot for the Cure Foundation

Soil compounds that may affect NTM growth Enhances NTM Growth Reduces NTM Growth

10 8 **

)

** ** )

F ** F 7

8 0

(

s 6 s

c c 5

M 4 4 1 24 48 72 96 1 48 96 Hours post inoculation Hours post inoculation media alone media + HEMATITE media only media + GIBBSITE **, p < 0.001 **, p < 0.001

Main ore of iron. Main mineral form of aluminum hydroxide. Kauai – HH=83% (5/6) vs Non-HH=21% (6/28) Oahu– HH=90% (1 0/11) vs Non-HH=32% (18/57)

Maui – HH=75% (3/4) vs Non-HH=23% (5/22) Hawai’i Island – HH=73% (8/11) vs Non-HH=92% (12/13)